The perioperative surgical home: An innovative, patient-centred and cost-effective perioperative care model

Abstract

Contrary to the intraoperative period, the current perioperative environment is known to be fragmented and expensive. One of the potential solutions to this problem is the newly proposed perioperative surgical home (PSH) model of care. The PSH is a patient-centred micro healthcare system, which begins at the time the decision for surgery is made, is continuous through the perioperative period and concludes 30 days after discharge from the hospital. The model is based on multidisciplinary involvement: coordination of care, consistent application of best evidence/best practice protocols, full transparency with continuous monitoring and reporting of safety, quality, and cost data to optimize and decrease variation in care practices. To reduce said variation in care, the entire continuum of the perioperative process must evolve into a unique care environment handled by one perioperative team and coordinated by a leader. Anaesthesiologists are ideally positioned to lead this new model and thus significantly contribute to the highest standards in transitional medicine. The unique characteristics that place Anaesthesiologists in this framework include their systematic role in hospitals (as coordinators between patients/medical staff and institutions), the culture of safety and health care metrics innate to the specialty, and a significant role in the preoperative evaluation and counselling process, making them ideal leaders in perioperative medicine.

Full text

Special
article
The
perioperative
surgical
home:
An
innovative,
patient-centred
and
cost-effective
perioperative
care
model
Olivier
Desebbe
a,b,
*,
Thomas
Lanz
a
,
Zeev
Kain
c
,
Maxime
Cannesson
c
a
Department
of
Anaesthesiology
and
Intensive
Care,
Clinique
de
la
Sauvegarde,
69009
Lyon,
France
b
Universite
´Lyon
1,
EA4169,
SFR
Lyon-Est
Sante
´,
Inserm
US
7,
CNRS
UMS
3453,
69000
Lyon,
France
c
Department
of
Anesthesiology
&
Perioperative
Care,
University
of
California
Irvine,
UC
Irvine
Medical
Center,
101
The
City
Drive
South,
Orange,
CA
92868,
USA
1.
Introduction
Increasing
costs
together
with
non-optimal
health
care
outcomes
is
leading
the
US
health
care
federal
agency
[Centers
for
Medicare
&
Medicaid
Services
(CMS)]
to
move
progressively
from
separate
payments
to
providers
for
individual
services
towards
a
single
payment
reimbursement
to
hospitals,
physicians,
and
other
providers
involved
in
the
overall
care
surrounding
each
surgical
episode
[1].
This
so
called
‘‘bundled
payments
for
care
improvement’’
initiative
is
forcing
caregivers
to
change
their
practice
model
and
may
lead
to
higher
quality
and
more
coordinated
care
at
a
lower
cost
for
medicare.
In
the
current
system
(pay
for
volume),
hospitals
and
providers
are
paid
for
each
service
provided
to
their
patients,
which
may
lead
to
increased
healthcare
expenditures.
In
the
‘‘bundled
payment’’
system
(pay
for
value),
hospitals
and
providers
will
have
to
optimize
the
expenses
to
outcome
ratio
in
order
to
increase
the
revenue
generated
for
each
care
episode.
Indeed,
the
shift
from
‘volume’
to
‘value’
is
not
limited
to
the
bundle
payment
initiative
but
includes
the
fee-for-service
model
as
well.
On
January
16th
2015,
the
Secretary
of
Health
and
Human
Services
indicated
that
by
2018,
her
intention
is
that
80%
of
all
payments
CMS
will
make
will
be
dependent
on
value
parameters
[2].
One
of
the
goals
associated
with
these
changes
is
to
force
hospitals,
groups,
and
providers
to
decrease
their
expenses
as
well
as
to
improve
the
patient
experience
and
clinical
outcomes
(decreased
incidence
of
Anaesth
Crit
Care
Pain
Med
35
(2016)
59–66
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Available
online
21
November
2015
Keywords:
Hospital
care
Perioperative
surgical
home
A
B
S
T
R
A
C
T
Contrary
to
the
intraoperative
period,
the
current
perioperative
environment
is
known
to
be
fragmented
and
expensive.
One
of
the
potential
solutions
to
this
problem
is
the
newly
proposed
perioperative
surgical
home
(PSH)
model
of
care.
The
PSH
is
a
patient-centred
micro
healthcare
system,
which
begins
at
the
time
the
decision
for
surgery
is
made,
is
continuous
through
the
perioperative
period
and
concludes
30
days
after
discharge
from
the
hospital.
The
model
is
based
on
multidisciplinary
involvement:
coordination
of
care,
consistent
application
of
best
evidence/best
practice
protocols,
full
transparency
with
continuous
monitoring
and
reporting
of
safety,
quality,
and
cost
data
to
optimize
and
decrease
variation
in
care
practices.
To
reduce
said
variation
in
care,
the
entire
continuum
of
the
perioperative
process
must
evolve
into
a
unique
care
environment
handled
by
one
perioperative
team
and
coordinated
by
a
leader.
Anaesthesiologists
are
ideally
positioned
to
lead
this
new
model
and
thus
significantly
contribute
to
the
highest
standards
in
transitional
medicine.
The
unique
characteristics
that
place
Anaesthesiologists
in
this
framework
include
their
systematic
role
in
hospitals
(as
coordinators
between
patients/medical
staff
and
institutions),
the
culture
of
safety
and
health
care
metrics
innate
to
the
specialty,
and
a
significant
role
in
the
preoperative
evaluation
and
counselling
process,
making
them
ideal
leaders
in
perioperative
medicine.
!
2015
Socie
´te
´franc¸aise
d’anesthe
´sie
et
de
re
´animation
(Sfar).
Published
by
Elsevier
Masson
SAS.
All
rights
reserved.
Abbreviations:
ASA,
American
Society
of
Anesthesiologists;
CMS,
centers
for
medicare
&
medicaid
services;
ERAS,
enhance
recovery
after
surgery;
GDP,
gross
domestic
product;
LOS,
length
of
stay;
N-SQIP,
National
Surgical
Quality
Improvement
Program;
OR,
operating
room;
PSH,
perioperative
surgical
home.
*Corresponding
author
at:
Department
of
Anaesthesiology
and
Intensive
Care,
Clinique
de
la
Sauvegarde,
Universite
´Lyon
1,
EA4169,
SFR
Lyon-Est
Sante
´,
Inserm
US
7,
CNRS
UMS
3453,
ba
ˆtiment
Trait
d’Union,
alle
´e
A,
e
´tage
5,
29,
avenue
des
Sources,
69009
Lyon,
France.
Tel.:
+33
6
51
05
80
65.
E-mail
addresses:
oldesebbe@yahoo.com
(O.
Desebbe),
lanzthomas@gmail.com
(T.
Lanz),
zkain@uci.edu
(Z.
Kain),
mcanness@uci.edu
(M.
Cannesson).
http://dx.doi.org/10.1016/j.accpm.2015.08.001
2352-5568/!
2015
Socie
´te
´franc¸aise
d’anesthe
´sie
et
de
re
´animation
(Sfar).
Published
by
Elsevier
Masson
SAS.
All
rights
reserved.
© 2016 Elsevier Masson SAS. Tous droits réservés. - Document téléchargé le 23/02/2016 par Lanz Thomas (80058)

complications,
decreased
length
of
stay.
.
.)
in
order
to
maintain
their
revenue.
In
this
context,
a
new
delivery
care
model
referred
to
as
the
perioperative
surgical
home
(PSH)
has
emerged
from
the
American
Society
of
Anesthesiologists
(ASA)
to
optimize
perioperative
care
[3].
The
PSH
is
a
patient-centred
micro
health
care
system
that
begins
at
the
time
of
the
decision
for
surgery
and
continues
until
physical
and
social
recovery
as
an
outpatient.
The
PSH
model
of
care
is
designed
to
help
achieve
the
triple
aim
proposed
by
the
Institute
for
Healthcare
Improvement
[4]:
!
improving
health;
!
improving
the
patient
care
experience
(quality
and
satisfaction);
!
reducing
health
care
costs.
While
the
PSH
incorporates
certain
components
of
enhanced
recovery
after
surgery
(ERAS),
it
is
a
broader
concept
that
uses
social
engineering
methods
and
performance
management
tech-
niques
(such
as
Lean
and
Six
Sigma)
to
optimize
care.
The
PSH
model
of
care
stresses
that
the
role
of
anaesthesiologists
is
branching
out
from
operating
rooms
(OR)
and
becoming
a
natural
source
of
leadership
for
coordinated,
perioperative
care
teamwork.
The
aim
of
this
manuscript
is
to
explain
the
rational
and
the
overall
concept
of
the
PSH
and
to
discuss
the
practical
aspects
of
its
implementation
at
individual
facilities.
2.
Rationale
for
implementing
a
new
model
of
care
An
interesting
combination
of
forces
is
naturally
driving
the
PSH
model
of
care
lead
by
anaesthesiologists.
These
forces
are:
!
the
increasing
cost
and
decreasing
quality
of
healthcare:
the
American
and
French
healthcare
systems
are
not
the
best
systems
anymore.
They
are
expensive
and
outcomes
(clinical
outcomes
and
patient
satisfaction)
are
not
improving.
The
portion
of
the
Gross
Domestic
Product
(GDP)
invested
in
healthcare
is
not
invested
elsewhere,
which
is
problematic
in
a
stalling
economy.
One
of
the
goals
of
the
PSH
is
to
improve
perioperative
outcomes,
while
decreasing
costs;
!
government
incentives:
in
the
US,
the
affordable
care
act
aims
at
a
universal
health
insurance
coverage,
which
will
mechanically
increase
healthcare
expenditures.
At
the
same
time,
by
modify-
ing
the
payment
system,
its
goal
is
to
contain
costs
for
each
care
episode.
In
the
perioperative
environment
(fragmented
and
expensive)
[5],
one
of
the
goals
of
the
PSH
model
of
care
is
to
make
this
care
accessible
in
a
highly
protocolised
environment;
!
pressure
on
Anaesthesiology
as
a
profession:
the
value
of
physician
anaesthesiologists
is
decreasing.
As
concerns
ASA
I
or
II
patients,
if
anaesthesiologists
are
confined
to
a
purely
intraop-
erative
role,
the
latter
is
likely
to
become
obsolete
(too
expensive
for
no
difference
in
outcomes
compared
to
midlevel
providers).
We
(i.e.
anaesthesiologists)
need
to
change
our
value
proposition
and
move
from
a
purely
intraoperative/critical
care
environ-
ment,
to
a
perioperative
medicine
approach,
where
we
can
help
improve
the
perioperative
process
of
care.
Below
is
a
detailed
analysis
of
the
driving
forces
leading
the
PSH
model
of
care.
2.1.
Increasing
costs
and
decreasing
healthcare
quality
The
US
health
care
system
presents
growing
health
care
expenditures,
estimated
at
$8,508
per
capita
and
representing
16.9%
of
the
GDP
[6].
Despite
that
the
US
is
ranked
first
for
healthcare
expenditures,
the
Commonwealth
Fund
reported
a
corresponding
low
quality
of
care,
ranking
the
US
as
11th
out
of
the
evaluated
countries
[7].
The
French
health
care
system
presents
similar
problems,
with
health
care
spending
representing
$4,118
per
capita
(11.6%
of
the
GDP)
associated
with
a
deficit
of
7.3
billion
euros
[8]
for
a
quality
of
care
ranked
9th
[7].
The
definition
of
quality
of
care
is
based
on
six
dimensions:
!
effectiveness;
!
efficiency;
!
accessibility;
!
acceptability/patient-centeredness;
!
equity;
!
safety
[9].
Several
factors
held
in
common
between
the
USA
and
France
have
historically
prevented
improvement
of
the
current
delivery
of
perioperative
care.
First,
the
fee-for-service
payment
system
(pay
for
volume)
leads
to
an
increased
demand
for
care
[10],
which
drives
costs
up
and
does
not
provide
incentives
for
improving
outcomes.
Indeed,
as
each
service
leads
to
a
payment,
the
fee-
for-service
system
encourages
the
multiplicity/redundancy
of
lab
tests
and
specialist
consults
prior
to
surgery.
This
approach
also
creates
a
fragmented
model
of
care,
where
patients
are
spread
across
multiple
care
providers
and
institutions
[5].
Second,
perioperative
care
providers
are
likely
to
work
alone,
which
contributes
to
increased
individual
management,
lack
of
applica-
tion
of
evidence-based
protocols,
human
errors
and
therefore
variation
in
delivery
of
care
to
patients
[11].
The
latter
may
be
further
explained
by
the
fact
that
the
concept
of
‘‘quality
of
care’’
is
pretty
recent.
For
example,
physician
training
and
culture
has
been
historically
focused
on
pathologies
rather
than
on
patients
and
the
overall
concepts
of
‘‘quality’’
and/or
‘‘system
issues’’
have
always
been
a
secondary
concern.
We
now
realize
that
our
practice
needs
to
shift
and
become
more
quality
and
patient-centred.
As
Lienhard
mentioned
in
a
French
survey
on
mortality
related
to
anaesthesia
in
2006,
‘‘Much
remains
to
be
done
to
improve
compliance
of
physicians
to
standard
practice
and
to
improve
the
anaesthetic
system
process.’’
[12].
2.2.
Government
incentives
In
order
to
solve
the
contradiction
posed
by
low
health
insurance
coverage
associated
with
high
health
care
costs,
the
Affordable
Care
Act
is
a
US
law
that
made
health
insurance
compulsory
for
all
American
citizens
[13].
What
is
less
known
in
France
is
that
this
American
law
introduced
various
tools
to
decrease
health
care
costs,
wherein
four
directly
impact
perioper-
ative
care:
!
the
pay-for-performance
program
provides
a
bonus
to
health
care
providers
if
they
reach
agreed-upon
quality
or
performance
measures;
!
care
givers
are
incentivized
to
join
Accountable
Care
Organiza-
tions
and
the
National
Quality
Strategy
Program
[14];
!
hospital
readmissions
within
30
days
after
discharge
from
the
hospital,
new
hospital-acquired
conditions
and
poor
patient
experience
scores
lead
to
a
significant
decrease
in
payments
made
to
hospitals;
!
the
National
pilot
program
on
payment
bundling
drives
health
insurers
to
pay
for
a
set
of
services,
not
‘‘per
unit
of
care
delivered’’
under
the
fee-for-service
model.
Interestingly,
similar
changes
have
been
observed
in
France.
Since
2008
in
France,
the
health
facility
payment
method
is
based
on
case-based
payments
or
diagnosis-related
groups
(DRGs)
O.
Desebbe
et
al.
/
Anaesth
Crit
Care
Pain
Med
35
(2016)
59–66
60
© 2016 Elsevier Masson SAS. Tous droits réservés. - Document téléchargé le 23/02/2016 par Lanz Thomas (80058)

(Groupement
Homoge
`ne
de
Malades,
Groupement
Homoge
`ne
de
Se
´jours)
balanced
by
patient
characteristics
or
perioperative
complications.
The
impact
of
this
activity-based
funding
on
outcomes
is
not
straightforward
[15],
and
serious
complications
during
the
patient
stay
lead
to
additional
expenses
for
the
facility
and
for
care
providers.
Certain
modifications
could
occur
following
the
implementation
of
the
French
law
termed
‘‘Loi
de
Sante
´’’,
adopted
on
April
14th,
2015.
This
law
includes
a
proposition
to
‘‘modify
care
towards
the
need
of
the
patient,’’
which
could
be
rephrased
as
a
‘‘patient-centred
clinical
pathway’’
[16].
This
law
also
tackles
the
issues
of
bundled
payment
organization
and
patient
accountability.
However,
no
penalty
or
reward
for
improving
the
quality
of
perioperative
care
is
proposed.
2.3.
Pressure
on
anaesthesiology
as
a
profession
When
examining
the
evolution
of
anaesthesiology
as
a
profession
over
the
past
50
years,
two
main
characteristics
strike
the
observer.
First,
our
specialty
has
been
a
leader
in
developing
patient
safety
concepts
and
mortality
related
to
anaesthesia
has
decreased
from
373
per
million
procedures
in
the
1950s’
to
less
than
8
per
million
today
[17].
No
other
medical
specialty
has
pushed
the
envelope
of
patient
safety
as
far
as
anaesthesiologists
have.
The
second
striking
observation
is
that
this
increase
in
patient
safety
has
been
paralleled
by
a
decrease
in
physician
anaesthesiologists’
involvement
in
direct
patient
care.
As
a
matter
of
fact,
one
physician
anaesthesiologist
was
required
per
anaesthesiology
procedure
in
the
1950’s,
while
today
one
physician
anaesthesiologist,
with
the
assistance
of
midlevel
providers
such
as
nurse
anaesthetists,
can
supervise
(‘medical
supervision’)
up
to
four
simultaneous
anaesthesia
procedures.
The
ratio
of
physician
anaesthesiologists
to
nurse
anaesthetists
can
reach
up
to
1:7
under
a
‘‘medical
direction’’
model.
This
development
may
become
a
problem
for
physician
anaesthesio-
logists
when
one
considers
that
the
cost
of
a
nurse
anaesthetist
is
half
that
of
a
physician
anaesthesiologist
in
the
United
States
and
when
some
states
(e.g.
California),
now
allow
midlevel
providers
to
provide
anaesthesia
under
the
supervision
of
any
physician
(including
surgeons)
[18].
According
to
the
‘‘Loi
de
Sante
´’’,
this
practice
may
soon
exist
in
France
[19].
Indeed,
the
second
chapter
of
this
law,
article
30,
extends
the
scope
of
nursing
with
the
creation
of
a
status
of
nurse
practitioner
(‘‘infirmier
clinician’’),
particularly
in
the
field
of
chronic
diseases.
These
new
projects
may
also
result
in
expanding
roles
for
nurse
anaesthetists.
Thus,
given
the
current
environment,
physician
anaesthesiologists
may
become
obsolete
for
the
provision
of
services
to
ASA
I
and
II
patients
if
they
do
not
change
their
value
proposition.
By
remaining
confined
to
operating
rooms,
our
value
compared
to
midlevel
providers
may
not
be
worth
the
gap
in
payment.
The
place
occupied
by
anaesthesiologists
in
the
surgical
ward
is
fuzzy
[20,21].
If
the
role
of
anaesthesiologists
in
the
surgical
ward
is
merely
counselling
(on
medical
complications
or
pain
control
management),
we
will
only
further
contribute
to
the
fragmented
nature
of
the
current
model
of
care
[22].
Overall,
we
hypothesize
that
anaesthesiologists
are
currently
faced
with
a
unique
opportunity:
our
expertise
together
with
the
external
pressures
on
our
profession
puts
us
in
a
position
where
we
must
venture
out
of
the
operating
room
in
order
to
solve
the
issues
related
to
the
perioperative
environment.
Doing
so
will
allow
us
to
lead
the
changes
required
for
optimizing
the
perioperative
process,
while
simultaneously
increasing
our
value
proposition.
3.
Basis
of
the
PSH
model
of
care
Recognizing
that
perioperative
care
is
a
major
component
of
total
health
expenditures,
the
American
Society
of
Anesthesiolo-
gists
introduced
the
concept
of
the
perioperative
surgical
home
(PSH),
akin
to
the
medical
home
model
developed
in
the
primary
care
setting
[23].
Once
again,
PSH
is
defined
as
a
micro
health
care
system
centred
on
the
patient
from
the
time
of
the
decision
for
surgery
to
the
physical
and
social
recovery
as
an
outpatient
up
to
30
days
after
discharge
from
the
hospital
with
a
triple
aim
(Fig.
1)
of
improving
(i)
clinical
outcomes
and
the
(ii)
patient
experience,
as
well
as
(iii)
reducing
health
care
costs
[24].
The
approach
of
this
future
health
care
system
is
summarized
in
Table
1.
We
hypothe-
size
that
the
PSH
concept
can
be
the
focus
of
a
French
project
coordinated
by
the
French
Society
of
Anaesthesiologists
[Socie
´te
´
franc¸aise
d’anesthe
´sie
et
de
re
´animation
(Sfar)],
broadening
the
skills
of
our
future
practice
[25].
The
PSH
is
based
on
five
principles
that
will
be
covered
below:
(i)
patient-centeredness,
(ii)
compre-
hensiveness,
(iii)
coordination
of
care,
(iv)
accessibility,
committed
to
(v)
quality
and
safety
[26].
3.1.
An
accountable
clinical
pathway
for
patient-centred
care
(comprehensiveness
and
accessibility)
In
the
PSH
model
of
care,
the
perioperative
clinical
pathway
is
centred
on
the
patient
rather
than
on
the
physician
(Fig.
2),
ensuring
that
caregivers
and
family
members
are
engaged
as
partners
as
concerns
a
given
patient’s
care.
Coaching
and
education
are
vital
for
the
accountability
of
the
active
patient
[27].
Fig.
1.
The
triple
aim:
improved
clinical
outcome,
improved
patients
satisfaction,
decreased
cost.
Patients,
care
providers
and
payers
interact
to
optimize
the
health
care
system
within
an
accountable
care
organization.
O.
Desebbe
et
al.
/
Anaesth
Crit
Care
Pain
Med
35
(2016)
59–66
61
© 2016 Elsevier Masson SAS. Tous droits réservés. - Document téléchargé le 23/02/2016 par Lanz Thomas (80058)

The
clinical
pathway
is
modelled
according
to
the
time
frames
associated
with
the
different
stages
of
management:
decision
for
surgery,
preoperative
assessment,
hospital
admission,
pre-,
intra-,
and
postoperative
care,
secondary
care
facility,
home
discharge
and
return
to
daily
activities.
It
is
of
major
importance
to
understand
that
involvement
in
post
hospital
care
is
critical
because
this
period
represents
up
to
40%
of
the
expenses
related
to
a
given
surgery.
This
seamless
continuity
of
care
(comprehensive-
ness)
would
reduce
unnecessary
preoperative
testing
and
consul-
tation
services,
as
well
as
day-of-surgery
cancellations
[28].
It
has
recently
been
shown
that
improving
each
milestone
throughout
the
process
can
decrease
the
postoperative
length
of
stay
(LOS)
[29].
Post-acute
care
(nursing
facilities,
medical
homes)
can
also
be
a
major
part
of
the
pathway
cost,
thus
further
indicating
the
need
to
optimize
every
stage
of
patient
care
[1].
Also,
new
approaches
are
being
developed,
such
as
home-visits
by
nurses
[30]
and
postoperative
consultations
with
patients
self-reporting
progress
via
electronic
media
(accessibility)
[31].
Nevertheless,
the
adapta-
tion
of
the
PSH
in
the
outpatient
setting
has
yet
to
be
described
[32].
It
should
be
stressed
that
PSH
benchmarks
the
quality
of
recovery,
which
is
widely
desired
by
physicians
[33],
beyond
the
simple
metric
of
LOS
[34].
3.2.
The
physician
anaesthesiologist:
the
perioperative
team
leader
(coordination)
The
patient-centred
pathway
design
needs
to
be
spearheaded
by
an
accountable
physician-leader
within
a
perioperative
team.
Coordinated
care
will
be
accomplished
mostly
by
breaking
silos
between
specialties
through
effective
communication
and
mutual
monitoring.
Obtaining
feedback,
as
well
as
analysing
behaviour
markers,
enhances
the
perioperative
team
performance
and
ensures
optimal
patient
safety
[35].
Anaesthesiology
appears
to
be
the
physician
specialty
the
most
appropriately
prepared
to
provide
such
comprehensive
perioperative
medicine.
Our
unique
qualities
include
our
universal
and
diverse
roles
in
hospitals
(coordinator
between
patients/medical
staff
and
institutions),
our
culture
of
safety
and
health
care
metrics,
and
our
role
in
preoperative
evaluation
and
counselling
[28].
The
perioperative
physician
would
rapidly
establish
a
reasonable
model
supported
by
others
by
implementing
and
coordinating
care
(‘‘from
home
to
recovery
at
home’’),
improving
staff
matching,
leveraging
resource
allocation
for
each
patient’s
requirements,
and
accounting
for
the
costs
of
patient
care
[36].
A
nurse
practitioner
serving
as
the
patient’s
‘‘perioperative
transition
coach’’
[24]
could
follow
the
patient
on
a
daily
basis
and
ensure
achievement
of
each
pathway
milestone.
3.3.
Real-time
access
to
best
practices
and
engineering
strategies
to
propose
and
sustain
a
seamless
quality
of
care:
a
commitment
to
quality
and
safety
Perioperative
medicine
has
to
deliver
the
best
possible
pre-,
intra-
and
postoperative
care
to
meet
the
needs
of
patients
undergoing
surgery
[37]
(Fig.
3).
The
efficient
design
of
related
clinical
pathways
calls
for
the
implementation
of
evidence-based
medicine
and
social
engineering
strategies
that
make
use
of
Information
Technology
(IT).
Individualized
care
based
on
intuitive
decision-making
by
physicians
should
be
replaced
by
a
multidis-
ciplinary
‘‘PSH
model’’
using
standardized
protocols.
The
underly-
ing
concept
is
to
reduce
variation
originating
from
system
heterogeneity
and/or
differences
in
practice
among
doctors
(‘‘variability
is
the
enemy
of
quality’’),
while
allowing
some
variability
based
on
individual
patients.
Evidenced-based
pro-
tocols
and
checklists
can
not
only
decrease
human
error
[38],
but
can
also
allow
clinicians
to
embrace
a
broader
view
of
the
patient,
and
would
reduce
redundancy.
The
benefit
associated
with
evidence-based,
new
guidelines,
such
as
the
enhance
recovery
after
surgery
programs
(ERAS)
[39],
has
been
clearly
demonstrated
via
decreases
in
perioperative
morbidity;
the
latter
are
also
well
Table
1
Current
and
future
characteristics
of
healthcare
systems.
From
To
Pay
for
procedures
Pay
for
value
Fee-for-service
Case
rate/budgets/capitation
More
facilities/capacity
Better
access
to
appropriate
settings
Physicians/hospitals
acting
independently
Physicians/hospitals
collaborating
for
global
risk
Physicians
and
hospitals
working
in
parallel
Highly
accountable
care
organization
Hospital
centred
Patient-centred
Fragmented
care
Continuum
of
care
Treat
disease/episode
of
care
Maintain
health
Individual
improvement
Engineering
method
improvement
(Lean
Six
Sigma)
Fig.
2.
The
perioperative
surgical
home
model
of
care.
The
perioperative
surgical
home
(PSH)
is
a
patient-centred,
institution-led,
interdisciplinary
and
team-based
system
of
coordinated
care
that
guides
the
patient
through
the
entire
surgical
continuum,
from
the
surgical
decision
to
full
recovery;
the
PSH
is
provided
by
a
preoperative
assessment
to
generate
a
ranked
and
seamless
continuity
of
care.
Care
providers
revolve
around
the
patient;
performance
measures
analyse
patient
evolution
and
provide
a
quality
improvement
process.
O.
Desebbe
et
al.
/
Anaesth
Crit
Care
Pain
Med
35
(2016)
59–66
62
© 2016 Elsevier Masson SAS. Tous droits réservés. - Document téléchargé le 23/02/2016 par Lanz Thomas (80058)

integrated
in
PSH.
As
an
example,
ERAS
in
colorectal
surgery
is
based
on
approximately
20
items
spanning
the
pre,
intra
and
postoperative
periods
(Table
2)
[39,40].
Beyond
simply
editing
the
protocol,
costs
and
sustainability
issues
associated
with
its
implementation
should
be
thoroughly
monitored
[41,42].
Further-
more,
protocols
streamline
human
tasks
(i.e.
applying
anaesthesia
protocols
would
allow
nurse
anaesthetists
to
be
more
indepen-
dent)
[25]
and
would
therefore
allow
anaesthesiologists
to
embrace
their
role
as
perioperative
physicians.
Protocols
should
be
associated
with
preoperative
clinical
decision
tools
[43]
that
increase
the
efficiency
of
various
treatments,
while
also
improving
protocol
compliance
and
decreasing
overall
practice
variability
[44].
For
example,
a
preoperative
consult
describing
a
history
of
sleep
apnoea
for
a
given
patient
would
alert
anaesthesiologists,
who
would
then
avoid
preoperative
benzodia-
zepines,
a
relative
contraindication
for
ambulatory
procedures.
Combined
with
anaesthesia
information
management
systems
(AIMS),
perioperative
cognitive
aids
can
be
designed
to
provide
real-time
decision
support,
thus
helping
avoid
human
errors.
For
instance,
a
low
mean
arterial
pressure
combined
with
a
high
minimum
alveolar
concentration
inhaled
drug
(recorded
by
the
AIMS)
might
generate
an
alert
subsequently
sent
to
the
care
provider’s
cell
phone
[45].
A
step
closer
to
automatic
management
is
closed-loop
systems,
wherein
the
speed
of
a
continuous
infusion
can
be
rapidly
(quasi-instantaneously)
modified
by
the
real-time
measurement
of
the
desired
effect
[46].
Beyond
protocol
implementation,
social
engineering
strategies
derived
from
the
manufacturing
industry
can
improve
cost-
effectiveness
and
should
be
implemented
within
the
PSH
model
of
care.
For
instance,
Lean
and
Six
Sigma
methodologies
streamline
care
(removal
of
waste
from
a
value
stream)
and
focus
on
reducing
variation
and
‘defects’
within
a
process
according
to
the
DMAIC
cycle:
Define
the
opportunity,
Measure
the
baseline
performance,
Analyse
the
root
causes,
Improve
the
process,
Control
the
improved
process
to
prevent
regression.
This
highly-reliable
care
organiza-
tion
approach
is
focused
on
both
processes
and
outcomes.
The
addition
of
multiple
small
cycles
for
rapid
improvement
achieves
an
overall
better
outcome.
Applied
to
healthcare-delivery
systems,
the
DMAIC
cycle
has
contributed
to
the
development
of
goal-
directed
protocols,
resulting
in
decreased
LOS
[42].
By
eliminating
waste
and
redundancy,
this
improved
care
can
be
achieved
in
a
cost-effective
manner.
3.4.
Full
transparency
with
continuous
monitoring
and
reporting
of
quality
of
care
and
cost
data
The
continuous
monitoring
of
performance
measures
tracks
patient
progress
within
the
PSH
model
of
care
and
guides
process
improvement
in
order
to
decrease
health
care
costs
[47].
All
metrics
are
stored
in
a
data
mart.
Metric
results
provide
feedback
to
institutions
enabling
modification
of
clinical
pathway
protocols,
if
deemed
necessary
(Table
3).
Feedback
would
also
lead
to
improved
compliance,
lower
variability
of
care,
and
enable
physicians
to
enhance
delivery
of
care.
Within
a
framework
of
multidisciplinary
teamwork,
anonymous
quality
assurance
report-
ing
is
needed
to
rapidly
modify
individual
behaviours
or
established
protocols
in
order
to
learn
from
mistakes,
regardless
of
their
origin
[48].
On
a
national
scale,
the
National
Surgical
Quality
Improvement
Program
(N-SQIP)
in
the
United
States
has
applied
this
approach
by
reporting
readmission
rates
(transparency)
[49].
N-SQIP
reporting
has
enhanced
quality
of
care
by
influencing
‘‘subpar
caregivers’’
towards
improved
delivery
of
care.
Adoption
of
the
N-SQIP
to
improve
safety
is
widely
recommended
[50].
Fig.
3.
Tools
allowing
implementation
of
the
perioperative
surgical
home
(PSH)
model
of
care.
Table
2
Checklist
of
Enhanced
Recovery
After
Surgery
(ERAS)
Group
recommendations.
Propositions
Preoperative
Preadmission
information
and
counselling
Preoperative
bowel
preparation
Preoperative
fasting
and
preoperative
carbohydrate
loading
Same-day
admission
Pre-anaesthetic
medication
avoidance
Antimicrobial
prophylaxis
Intraoperative
Standard
anaesthetic
protocol
Balanced/multimodal
analgesia
Goal-directed
therapy
Minimally
invasive
techniques
High
oxygen
concentrations
Preventing
intraoperative
hypothermia
Avoidance
of
drains
and
lines
Postoperative
Early
mobilization
and
oral
intake
Prophylaxis
against
thromboembolism
Preventing
and
treating
postoperative
nausea,
vomiting
and
ileus
Balanced
analgesia
Early
removal
of
drains,
lines
and
urinary
catheters
Audit
Adapted
from
[39,40].
O.
Desebbe
et
al.
/
Anaesth
Crit
Care
Pain
Med
35
(2016)
59–66
63
© 2016 Elsevier Masson SAS. Tous droits réservés. - Document téléchargé le 23/02/2016 par Lanz Thomas (80058)

4.
Implementing
the
PSH
strategy
in
our
institution:
a
new
challenge
for
the
anaesthesiologist
The
PSH
model
of
care
is
an
opportunity
for
French
anaesthesiologists
to
embrace
new
dimensions:
by
consistently
measuring
our
practice
and
patient
outcomes/satisfaction,
we
would
improve
our
delivery
of
care.
In
tailoring
our
care
process
by
focussing
it
on
the
patient,
we
would
decrease
care
variability
while
encouraging
a
patient
individualized
approach.
4.1.
Assessment
of
local
perioperative
management
A
necessary
first
step
that
must
be
carried
out
before
applying
a
coordinated
strategy
is
the
description,
quantification
and
questioning
of
the
current
perioperative
patient
management
process.
What
is
the
clinical
pathway
(consults,
lab
tests,
hospital
admission,
perioperative
care,
and
home
discharge
until
full
recovery)?
How
do
all
perioperative
care
providers
(physicians,
paramedics
and
administrative)
interact?
How
is
care
provided:
use
of
evidence-based
protocols,
use
of
tools
allowing
quantifica-
tion
of
patient
states
(comorbidity
and
satisfaction
scales)
and
quality
of
care?
Last
but
not
least,
what
is
the
cost
of
each
part
of
this
micro
health
care
system
(consults,
patient
movements,
lab
tests,
hospital
stay,
care
provider
fees,
etc.)?
4.2.
Implementation
of
PSH
in
local
institutions
The
assessment
of
the
local
perioperative
environment
would
serve
as
a
basis
for
the
reorganization
of
care.
Importantly,
implementation
depends
on
local
constraints
(i.e.
an
efficient
PSH
in
a
dedicated
area
might
not
be
as
efficient
in
a
different
location)
[51].
A
PSH
is
organized
according
to
a
personalized
and
evidence-
based
care
plan,
coordinated
by
a
leader
from
a
perioperative
team.
Implementing
a
new
perioperative
approach
would
ideally
lead
to
care
improvements,
increased
patient
and
physician
satisfaction,
[52,53]
and
cost
savings.
4.3.
Key
elements
to
insure
the
success
of
PSH
Anaesthesiologists
and
dedicated
surgeons,
together
with
colleagues
from
all
perioperative
hospital
services,
should
develop
and
implement
a
series
of
clinical
care
pathways
defining
and
standardizing
pre-,
intra-,
postoperative
and
post-discharge
management
for
a
specific
group
of
patients.
Commitment
to
the
goals
from
multiple
disciplines
in
establishing
protocols
and
implementing
clinical
pathways
ensures
their
buy-in,
easing
the
transition
from
a
traditional
surgical
practice
to
a
standardized
and
coordinated
care
delivery
model.
In
practice,
the
clinical
pathway
should
be
displayed
using
process
mapping
techniques
on
a
large
spreadsheet
with
all
tailored
protocols
and
standardized
clinical
assessment
and
management
protocols
(SCAMPs)
[24].
A
steering
committee
(PSH
team,
including
a
dedicated
nurse
[54])
is
created
and
should
meet
regularly
to
follow
PSH
implementation
and
SCAMPs.
The
use
of
Lean
Six
Sigma
engineering
and
metrics
provides
a
strict
monitoring
system
for
the
clinical
pathway
with
any
deviations
managed
by
the
PSH
team.
The
orchestration
of
the
PSH
implementation
process
by
a
quality
improvement
specialist
and
a
project
coordinator
can
be
very
useful.
As
previously
mentioned,
outcome
measures
need
to
be
quantified
by
metrics
Table
3
Lexicon.
Accessibility
‘‘Patients
and
their
families
must
be
able
to
contact
PSH
providers
at
all
times’’
[26]
Accountable
Care
Organization
Groups
of
doctors,
hospitals,
and
other
health
care
providers,
who
come
together
voluntarily
to
give
coordinated
high
quality
care
to
initially
medicare
patients
High
quality
of
the
right
care
at
the
right
time,
while
avoiding
unnecessary
duplication
of
services
and
preventing
medical
errors
[59]
Affordable
Care
Act
Health
insurance
reforms
that
put
consumers
back
in
charge
of
their
health
care
To
make
health
care
more
affordable,
accessible
and
of
a
higher
quality
Bundled
payment
Paying
for
a
set
of
services
Reimbursement
of
health
care
providers
‘‘on
the
basis
of
expected
costs
for
clinically-defined
episodes
of
care’’
Centers
for
Medicare
&
Medicaid
services
(CMS)
Federal
agency
that
runs
the
medicare
program
(public
health
insurance
program
for
people
age
65
or
older,
or
with
certain
disabilities)
CMS
works
with
the
states
to
run
the
medicaid
program
(public
health
insurance
program
for
incomes
<
$29,700
for
a
family
of
four)
Committed
to
quality
and
safety
Perioperative
medicine
has
to
deliver
the
best
possible
perioperative
care
to
meet
the
needs
of
patients
undergoing
surgery
in
using
evidence-based
protocols
allowing
for
decreasing
variability
of
practice
Comprehensiveness
Seamless
continuity
of
care
spanning
the
entire
patient
pathway
Coordination
The
‘‘deliberate
organization
of
patient
care
activities
between
two
or
more
participants
(including
the
patient)
involved
in
a
patient’s
care
to
facilitate
the
appropriate
delivery
of
health
care
services’’
[60]
‘‘The
PSH
model
requires
coordination
between
all
phases
of
the
perioperative
process:
from
the
surgeon’s
office
to
the
preadmission
testing
process,
through
the
pre-,
intra-
and
postoperative
periods
in
the
hospital
and
lastly,
the
post-discharge
process
at
a
skilled
nurse
facility
or
at
home’’
[50]
Fee-for-service
A
method
in
which
doctors
and
other
health
care
providers
are
paid
for
each
service
performed
[61]
Metrics
Performance
measures,
clinical
data
reporting
Quantitative
measurement
of
delivery
of
care
and
outcomes
Provide
the
ability
to
track
patient
progress
during
their
time
in
the
PSH,
generate
reports
on
the
functioning
of
the
PSH
and
guide
process
improvement
Ex:
National
Anesthesia
Clinical
Outcomes
Registry
(NACOR)
N-SQIP
The
National
Surgical
Quality
Improvement
Program,
a
nationally
validated,
risk-adjusted,
outcomes-based
program
to
measure
and
improve
the
quality
of
surgical
care
Patient-centeredness
Perioperative
‘‘health
care
that
establishes
a
partnership
among
practitioners
and
patients,
and
their
families
to
ensure
that
decisions
respect
patients’
wants,
needs,
and
preferences
and
that
patients
have
the
education
and
support
they
need
to
make
decisions
and
participate
in
their
own
care’’
[62]
Pay-for-performance
(P4P)
Performance
measures
for
quality
and
efficiency.
It
penalizes
caregivers
for
poor
outcomes,
medical
errors,
or
increased
costs
Value-based
purchasing
Triple
aim
An
approach
towards
optimizing
health
system
performance
by
simultaneously
developing
three
dimensions:
improving
the
patient
experience
of
care
(including
quality
and
satisfaction),
improving
the
health
of
populations,
and
reducing
the
per
capita
cost
of
health
care
Developed
by
the
‘‘Institute
for
Health
care
Improvement’’,
an
independent
not-for-profit
organization
PSH:
perioperative
surgical
home.
O.
Desebbe
et
al.
/
Anaesth
Crit
Care
Pain
Med
35
(2016)
59–66
64
© 2016 Elsevier Masson SAS. Tous droits réservés. - Document téléchargé le 23/02/2016 par Lanz Thomas (80058)

from
a
health
care
database,
including
process
outcome,
clinical
outcome,
and
financial
outcome
metrics.
4.4.
Potential
challenges
to
the
implementation
of
a
PSH
model
Several
barriers
can
appear
on
the
road
to
PSH
implementation:
finding
physicians
with
proper
leadership
skills,
achieving
consensus
between
all
stakeholders
(particularly
with
surgeons
and
administrations),
and
adherence
to
the
standardization
of
care.
One
way
to
convince
physicians
and
ensure
their
engagement
is
to
audit
actual
practice
by
choosing
a
common
surgery
in
an
institution
and
to
evaluate
patient
satisfaction,
cost,
morbidity,
LOS,
and
recovery.
This
analysis
brings
up
a
second
potential
problem:
the
cost
of
analysis,
development
of
electronic
medical
record
order
sets,
and
dedicated
employees
to
work
on
PSH.
Funding
up
front
may
be
difficult
but
the
financial
benefits
after
a
successful
implementation
far
outweigh
the
initial
investment.
Finally,
another
difficulty
could
be
physician
compensation
expectations.
One
simple
way
to
keep
staff
motivated
is
to
report
outcome
progress
and
maintain
PSH
educational
opportunities
that
could
help
in
improving
multidisciplinary
care
team
dynam-
ics.
4.5.
Education
to
drive
the
concept
of
PSH
Educational
measures
and
the
corresponding
computer
soft-
ware
are
essential
for
the
success
of
any
new
care
strategy.
Current
medical
studies
focused
on
pathology,
diagnosis,
and
treatment
should
transition
to
include
factors
describing
quality
of
care
(safety,
effectiveness,
patient-centeredness,
timeliness,
efficiency,
equitability)
[55],
as
well
as
those
derived
from
the
sociologic
and
economic
health
sciences.
Simulation
is
also
a
novel
learning
tool
that
contributes
to
improving
individual
tasks
[56]
and
teamwork
(to
explore
interactions
between
care
providers,
patients,
team
management,
etc.)
[57].
Importantly,
in
order
to
highlight
the
new
role
of
the
anaesthesiologist
as
a
perioperative
physician,
PSH
education
should
be
included
in
residency
training.
Fellowships
are
also
an
effective
approach
for
training
and
dispersing
such
a
novel
paradigm
shift
in
clinical
care.
Education
of
the
general
population
and
medical
community
is
also
warranted
(national
advertising
campaigns
and
relevant
publications)
to
optimize
positive
impacts
[58].
Patients
should
also
be
held
accountable
for
their
care
and
accept
the
collaborative
role
between
themselves
and
their
physician
in
order
to
be
better
satisfied
with
the
delivery
of
their
health
care
[27].
5.
Conclusion
The
PSH
model
may
be
a
precursor
to
a
future
perioperative
health
care
system
by
not
only
more
effectively
treating
disease
but
also
by
benchmarking
patient
recovery
in
a
cost-effective
manner.
Additionally,
the
PSH
paradigm
may
help
institutions
respond
to
potential
reimbursement
cuts
secondary
to
future
bundle
payments,
penalties
for
readmissions
and
the
movement
from
volume
to
value.
Such
a
new
approach
requires
us
to
be
open
minded
in
accepting
constant
evaluation,
integrating
automated
processes,
and
overseeing
the
patient
rather
than
maintaining
a
fragmented
role.
PSH
necessitates
major
structural
and
work-flow
changes
and
questions
our
work
habits
through
direct
and
indirect
measurement
of
our
skills,
examining
medical
practice
as
a
science
but
also
with
the
goal
of
reaching
a
higher
patient
satisfaction
level.
Anaesthesiologists
are
ideally
positioned
to
lead
PSH
initiatives
and
should
benchmark
higher
standards
of
care
by
being
active
team
leaders
for
this
individualized,
patient-centred,
perioperative
pathway.
As
with
every
new
concept,
discussion
is
necessary:
PSH
implementation
will
require
significant
financial
resources
and
concrete
evidence
to
prove
its
cost-effectiveness,
sustainability,
and
improvement
in
both
patient
and
physician
satisfaction.
Disclosure
of
interest
The
authors
declare
that
they
have
no
competing
interest.
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